Clinical Tips, General Updates, Podcast

Podcast Episode 11 – Bill Kahler on the Magic of Regenerative Endodontics

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Bill Kahler is an Endodontist practicing in Brisbane, Australia.

Bill Kahler, world leader in regenerative endodontics.

Bill Kahler is an Endodontist practicing in Brisbane, Australia. I’ve been keen to do a podcast examining the world of regenerative endodontics for a long time, and as it turns out I’m fortunate to have a world-class expert practicing in my home town. This episode is very technical and we get into the details of how and when regenerative endo can benefit our patients, as well as the areas that still need to be properly explored. I really do think you’re going to enjoy this episode.

iTunes

Podcast: Play in new window | Download

Show Notes and Links

Bill’s review article on Regenerative Endodontics

Bill’s JOE article on Regenerative Endodontics in Traumatised Teeth

Find Bill  on Facebook

Bill’s Practice website.

Clinical Tips, Endodontic Preparation Techniques, Podcast

Podcast Episode 2 – Antonis Chaniotis on Managing Difficult Anatomy and Traveling the World

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Antonis_Chaniotis

Antonis Chaniotis is an Endodontist practicing in Athens, Greece. He is one of the internet’s most famous dental educators and is passionate about teaching through the medium of video. He has a special interest in microsurgical endodontics, and the management of difficult endodontic anatomy. He gives us an insight into what it means to share your experience with devotees all over the world. 

iTunes

Podcast: Play in new window | Download

Show Notes and Links

Antonis’ Practice in Athens

Find Antonis on Facebook

Hyflex EDM Files

Recent Research on Hyflex EDM Files

Clinical Tips, Endodontic Preparation Techniques

Deep Split Buccal Canals of Upper Second Molar

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This case was referred as the dentist could only find two canals. The upper second molar will sometimes have the mesiobuccal and distobuccal canals very close, and sometimes the split will occur well below a a single, larger orifice.

Pre-operative Radiograph

Pre-operative Radiograph

The buccal canals split about 3mm below the orifice.

The buccal canals split about 3mm below the orifice.

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Palatal Canal

Amalgam Restoration

Amalgam Restoration

Post-Operative Radiograph

Post-Operative Radiograph

Pat Caldwell

Clinical Tips, Endodontic Preparation Techniques

Upper Pre-molars – The weakest Link?

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Upper pre-molars present as a special case when they require endodontic treatment. They are skinny, weak teeth in their virgin form, and once a marginal ridge is lost, or endodontic access is performed, their resistance to fracture drops significantly.

My opinion on these teeth is that the restorative needs trump the endodontic needs in the majority of cases. Endodontists I know who have conducted long term follow ups of their cases find this tooth to be in the higher failure category, and the failure is most commonly fracture of the tooth. There’s many ways to skin a cat, but this is how I handled this case. The only dentine removed was directly over the pulp horns. I’m still recommending an onlay/crown. I’m interested to hear how you would restore this in your practice.

 

Pre-op. There is a recently placed deep distal restoration. The patient reports symptoms of irreversible pulpitis.

Copious irrigation is used to remove as much pulp tissue as possible.

Copious irrigation is used to remove as much pulp tissue as possible.

The only dentine removed was that directly over the pulp horn. Conservation of pericervical dentine and the dentine connecting the mesial and distal parts of the tooth assists in maintaining strength.

The only dentine removed was that directly over the pulp horn. Conservation of pericervical dentine and the dentine connecting the mesial and distal parts of the tooth assists in maintaining strength.

GP filling the pulp chamber.

GP filling the pulp chamber.

 

GP Filling

GP Filling

Bitewing view of root filling and composite core showing minimal preparation.

Bitewing view of root filling and composite core showing minimal preparation.

Composite Core

Composite Core

 

Post-Op Radiograph showing two canals merging apically.

Post-Op Radiograph showing two canals merging apically.

 

Clinical Tips, Endodontic Preparation Techniques, General Updates

The Lower Second Molar. Tricky in So Many Ways.

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This case was referred as the treating dentist was astute enough to recognise that while some lower second molars only have two canals, the majority will have at least three. Only one orifice was visible mesially. The mesial roots of lower second (and third) molars are often challenging to treat for a number of reasons. Access can be difficult, there is often a double curve in the mesio-distal and bucco-lingual plane, and often we see a single orifice with two canals. This was one of those cases where only a single orifice was visible mesially.

Before attempting to tackle this case we took a CBVT. The CBVT presented a finding indicative of a second canal in the mesial root. This is good information to have, as if we suspect there are two canals, we know where to remove dentine in an attempt to locate the canal. If we suspect only one canal after viewing the CBVT, we don’t need to be needlessly removing further dentine in the all-important pericervical area.

 

The clinical picture is of one mesial orifice, but the CBVT indicates two canals.

The clinical picture is of one mesial orifice, but the CBVT indicates two canals.

The CBVT also tells us where to look – buccal or lingual of the orifice. In my experience, the classic situation for these canals is for the main canal to be the mesiobuccal, with the mesiolingual canal coming off the main canal a few millimetres below the orifice. The orifice to the second canal can be quite small, and as it comes off the main canal at a sharp, almost 90 degree angle, we have to be careful to open the canal coronally with some hand files before attempting to place a rotary file in it.

After removing about 2mm of dentin lingually to the existing orifice, the second canal was located.

After removing about 2mm of dentin lingually to the existing orifice, the second canal was located.

The final root filling with composite closing the access.

The final root filling with composite closing the access.

So there you have it. One more little gem in your bag of tricks for treating difficult anatomy. Have you had experience in cases such as this? Share your comments below.

Pat

Clinical Tips, Endodontic Surgery

The Compromise. Pre-Implant Apical Surgery.

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When it comes to compromised teeth, our goal may be to simply maintain a tooth for as long as possible. It also makes sense to plan for the future, so whenever I treat a tooth endodontically, I attempt to have all the possible outcomes in mind, including the eventual failure of the tooth.

This was such a case. The patient presented with a buccal sinus tract adjacent to the 11 (right central incisor). The 11 had been previously root treated. The tooth was mobile, but there were no periodontal pockets. To complicate matters an implant was present in the 12 position. The obvious treatment options were extraction, endodontic re-treatment and apical surgery.

Apicectomy

A large area of bone loss adjacent to an Implant. Careful planning is required.

I suspected that endodontic re-treatment was not going to be successful in resolving the infection. Re-treatment would also have the downside of further weakening the root as well as added expense and treatment time. The initial root treatment was done to a high standard by a dentist I know performs high quality work. I judged the likelihood of this being an endodontic treatment failure as low.

Extracting the tooth with such a large area of apical periodontitis and perforated buccal plate of bone also carries risks. I was concerned that extraction would allow a significant amount of soft tissue in-growth, compromising the amount of bone available for future implant placement. There is also the added aesthetic risk of loss of supporting tissues for the mesial aspect of the 12 implant. An augmentation procedure could be performed at the time of extraction, but given the acute infection, I would be concerned about the possibility of infection of the grafting material.

The left image shows removal of the pathological tissue. On the right, an apical crack can be seen.

The left image shows removal of the pathological tissue. On the right, an apical crack can be seen.

Ultimately, the patient elected to have apical surgery performed. A buccal flap was raised, sparing the papilla and the lesion curetted. The root was apicectomised. Upon inspection of the root under microscope, an apical fracture could be seen. This helps explain why no healing occured after initial endodontic treatment. I resected a few more millimetres to a level where no fracture was apparent. Staining with methylene blue showed a lateral canal. A retrofill with MTA was performed.

Further resection allowed removal of the crack. A lateral canal was seen and staining with methylene blue showed confirmed this. I knew there was a lateral canal at that level as during the initial removal of GP with ultrasonic, the GP could be seen expressing through the lateral canal. The image on the right is of the MTA retrofill.

Further resection allowed removal of the crack. A lateral canal was seen and staining with methylene blue confirmed this. I knew there was a lateral canal at that level as during the initial removal of GP with ultrasonic, the GP could be seen expressing through the lateral canal. The image on the right is of the MTA retrofill.

I have no doubt that simply suturing the flap in place in this case would still result in significant soft tissue fill of the defect left by removal of the apical pathology. Ultimately, our goal now was to regenerate as much bone as possible. We are dealing with a five walled defect, and the placement of calcium sulfate in the defect will help prevent soft tissue invasion, as well as allow replacement with native bone. I also wanted to avoid having to place either a rigid membrane (with later removal required) or having to pin a collagen membrane in place.

On the left the extend of the lesion can be seen with implant threads exposed. These were debrided and scrubbed. Calcium Sulfate was then used to fill the defect. Note the complete deshiscence.

On the left the extent of the lesion can be seen with implant threads exposed. These were debrided and scrubbed. Calcium Sulfate was then used to fill the defect. Note the complete deshiscence of bone over the central incisor.

The tooth was taken out of occlusion. It was lacking bony support prior to surgery and has even less post-surgery. Hopefully healing of the bone will facilitate further support of the tooth. It is possible that this tooth will fail, but it is also possible that the tooth could remain functional for a number of years. Ultimately, we have treated with an end-point in mind and given the complicated presenting situation, a compromise is the best that could be achieved at this stage.

The flap was closed tih 6/0 sutures. A sling suture was used to keep the flap coronally positioned. The Xray shows the MTA fill, as well as the limited periodontal support.

The flap was closed with 6/0 sutures. A sling suture was used to keep the flap coronally positioned. The Xray shows the MTA fill, as well as the limited periodontal support.

The tooth was relieved from occlusion.

The tooth was relieved from occlusion.

Would you have managed this differently? If so, please comment below.

Clinical Tips, Cracks in Teeth, Endodontic Radiography

Now you see it, now you don’t

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Sometimes in endodontics, we miss signs, symptoms or findings that are important to diagnosis or prognosis. Sometimes our brain fools us into thinking we see or find things that aren’t really present. This case is a good example of both of these possible errors. The patient presented complaining of mild tenderness to bite on the 26. The tooth was slightly tender to percussion, mobility was normal and there was slight tenderness to palpation on the palatal aspect. Periodontal probing was within normal limits. Here are the intra-oral radiographs:

Bitewing cracked tooth

PA - Cracked toothCracked tooth PA

I decided to take a CBVT scan. The main finding on the scan was a lucency at the mesiopalatal aspect of the marginal tissues.

CBVT_Crack1

CBVT_Crack3

CBVT_Crack2

My plan was now to raise a flap to investigate. Once LA had been applied I probed again. This time I found a narrow deep pocket at the mesiopalatal aspect of the tooth. The locating of a pocket after giving LA that had not been found prior to LA is something that happens in my practice on an occasional, but recurring basis. In fact, it’s been happening since one of my demonstrators made me look silly during my endo specialty program by finding a pocket that I said was never there. I think there are a couple of factors behind this:

1. We are happy to probe more firmly when the patient is numb;

2. Radiographic findings, especially on CBVT point you to a specific location to probe for a pocket.

In a case such as this, the symptoms, followed by the radiographic finding increases the probability of a fracture being present. The added finding of a deep, narrow pocket increases the probability even more. That said, the fracture is not confirmed until visualised. So, a flap was raised and the root surface stained with methylene blue. The visualised crack confirmed the diagnosis.

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The CBVT helped immensely in this case. However, it’s easy to look at the CBVT and think, “Ah, I see the crack!” (go back to the bottom CBVT image above and look again),  but also have a look around the rest of the teeth shown in the CBVT. Almost all of them seem to have lucent lines running through them that look like”cracks”. It is very dangerous to look at the lucent line on a CBVT and “diagnose” a crack. All we have in this case from the CBVT is a finding that may be typical of a pattern of bone loss associated with a crack. It added to the other findings to lead to the final confirmation of the diagnosis of cracked tooth via visual inspection.

Let me know your thoughts on this in the comments section below.

Pat Caldwell

Clinical Tips, Diagnosis of Pulpal Pathology, Endodontic Radiography

Perio-Endo? Get Some GP in it!

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The second most common reason for extraction of root filled teeth is periodontal disease. So it’s important we identify periodontal disease when deciding if we should treat a tooth. Periodontal pockets around teeth can generally be due to three things:

1. Periodontal disease;

2. Vertical root fracture;

3. A sinus tract draining through the PDL.

Usually, a true periodontal pocket will be broad, whereas a pocket due to a root fracture or a draining sinus will be very narrow. We are more likely to find a true periodontal pocket in a patient who suffers periodontal disease in other teeth besides the one we are looking at.

When we do identify a periodontal pocket in a tooth that also has apical periodontitis, we want to know if the periodontal disease is separate to the apical disease. When these two are combined in a perio/endo lesion, the success rate in treating the teeth is lower than when we have separate perio and endo disease. If the pocket is narrow, then it’s important to differentiate between the draining sinus (which may be easy to treat) and the root fracture, which cannot be treated. I usually do this by raising a flap and inspecting the root with the microscope after staining with methylene blue.

Endo Perio lesion

GP placed into a sinus tract helps determine the true depth of the sinus tract.

In cases where I find a very deep, broad periodontal pocket which I think may be to the apex of the tooth, I place a GP point in the pocket to full length and take a radiograph. If the GP extends to the apex, then I know we have a fight on our hands to save the tooth.

The Endospot

A true perio/endo lesion makes this tooth a difficult prospect for successful treatment.

In the comments section, please leave your tips on identifying perio/endo lesions.